Intoxicação por veneno de cobra: necrose symetrica da cortex renal: uremia

Memórias do Instituto Oswaldo Cruz, Feb 2019

In a mortal case of ophidism, in an individual 15 years old, bitten by a snake (Bothrops jararaca) on the external face of his right leg and who died 26 days after the accident, the AA. describe the pathologic-anatomical changes met with and the modifications of the metabolism put into evidence through chemical blood examinations. The main changes there existing are located in the kidneys, which present changes of diffused glomerulonephritis and the typic features of symmetrical cortical necrosis. Among the changes of greater significance there are, moreover, observed vascular injuries of great intensity and essentially constituted by a process of productive endoarteritis. The necrosis of the cortex renis, in view of the intensive vascular changes (productive endoarteritis) conveying the obliteration of the arteries, is considered as a direct consequence of such vascular changes. The renal vessels, which are the seat of the inflammatory process, are the interlobar, arciform and interlobular arteries, but mainly the arteriolary ramifications of the cortical layer. The process of endoarteritis always assumes a progressive character so that the vascular lumen, little by little, is getting obstructed. In opposition to what has been observed in the cases, quoted in the literature, of symmetrical necrosis of the cortex, in which the parenchymatous changes are consecutive to thrombosis of the renal vessels, in the present case this appearance was not verified, there being observed only the existence of obliterating productive endoarteritis. The AA. consider the kidney changes in their case as resulting from the slow and prolongated action of the snake venom on the renal structures, on the strength of the following facts already known and agreed to: elimination of snake venom through the kidneys; capability of the same venom of determining diffused glomerulonephritis, and action of snake venom on vascular endothelium, turned essentially easier by the specific function of the organ. The modifications of metabolism were shown by urine and blood changes. Urine was eliminated in very small quantities (50 cc. in 24 hours); yet, absolute anuria was not observed. Hyaline and granular casts, as well as white blood cells and kidney cells along with albuminuria, were present. Hematologic examination revealed 11% of hemoglobin; 960.000 red blood cells per cmm., and 5.200 leukocytes per cmm.; differential blood count revealed increase of neutrophil leukocytes along with 74% of segmentated ones. The rate between serum and clot was 9 x 3 cc. Wassermann's test in blood serum was negative. The chemical blood examinations revealed: Total proteins 7.61 grs per 100 cc.; Albumin 2.39 grs. per 100 cc.; Globulin 5.22 grs. per 100 cc.; Urca 6.42 grs. per 100 cc.; Fibrinogen 0.324 grs. per 100 cc.; Indican +++; Plasmal cl. 339 mgrs. in 100 cc.; Globular cl. 170 mgrs. in 100 cc.; Cholesterol 163 mgrs. in 100 cc.; Creatinin 260 mgrs. in 100 cc.; Inorganic phosph. 13.4 mgrs. in 100 cc.; Calcium 10.3 mgrs. in 100 cc.; Potassium 28 mgrs. in 100 cc.; Sodium 328 mgrs. in 100 cc.. The renal insufficiency in the case studied was shown by humoral modifications, particularly by increased azotemia, by the increase of creatinin, inorganic phosphorus and indican. In opposition to the existence of such modifications, the patient did not present the clinical evidence observed in cases in which azotemia is at a high degree, a fact which reproduces the clinical aspect as described for the symmetrical necrosis of cortex renis.

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Intoxicação por veneno de cobra: necrose symetrica da cortex renal: uremia

Intoxicação por veneno de cobra: necrose symetrica da cortex renal: uremia A. Penna de Azevedo J. de Castro Teixeira RESUMO Em um caso fatal de ophidismo, em individuo de 15 annos de edade, picado por uma cobra jararaca (Bothrops jararaca) na face externa da perna direita e que veio a fallecer 26 dias apoz o accidente, os A.A, descrevem as lesões anatomo-pathologicas encontradas e as modificações do metabolismo, evidenciadas pelos exames chimicos do sangue. As principaes alterações existentes, acham-se localisadas nos rins os quaes apresentam lesões de glomerulonephrite diffusa e o aspecto typico da necrose cortical symmetrica. Como alterações de maior significação observam-se ainda lesões vasculares de grande intensidade e constituidas essencialmente por processo de endoarterite productiva. A necrose symmetrica da cortex renal, a vista das intensas alterações vasculares (endoarterite productiva) que acarretaram a obliteração das arterías, é considerada como a consequencia immediata de taes lesões vasculares. Os vasos renaes, séde do processo inflammatorio, são as arterias interlobar, arciforme e interlobular, mas principalmente as arteriolares da camada cortical. O processo de endoarterite assume sempre o carater progressivo, de modo que a luz vascular vae sendo aos poucos, totalmente obstruida. Ao contrario do que se tem observado nos casos de necrose cortical symmetrica, citados na literatura, em que as alterações parenchymatosas são consequentes a thrombose dos vasos reanes, no caso presente esse aspecto não foi verificado mas tão sómente a existencia da endoarterite productiva obliterante. Consideram os A.A. as lesões renaes no caso que estudaram, como a resultante da actuação lenta e prolongada do veneno de cobra sobre as estructuras renaes, baseados nos seguintes factos já conhecidos e admittidos: eliminação do veneno de cobra pelos rins; capacidade do mesmo veneno, determinar a glomerulo-nephrite diffusa e acção do veneno de cobra sobre o endothelio vascular, facilitada essencialmente pela funcção especifica do orgão. As modificações do metabolismo se traduziram por alterações urinarias e sanguineas. As urinas foram emitidas em muito pequena quantidade (50 cc. em 24 horas) não havendo comtudo, anuria absoluta. Cylindros hyalinos e granulosos, bem como leucocytos e cellulas renaes, associadas á albuminoria, era presentes. Os exames chimicos do sangue, revelaram: Proteinas totaes 7,61 grs. em 1000 cc.; Albumina 2,39 grs em 1000 cc.; Globulina 5,22 grs. em 1000 cc.; Uréa 6,42 grs. em 1000 cc.; Fibrinogeneo 0,324 grs. em 1000 cc.; Indican +++; Cl. plasmatico 339 mgrs. em 100 cc.; Cl. globular 170 mgrs. em 100 cc.; Cholesterol 163 mgrs. em 100 cc.; Creatinia 260 mgrs. em 100 cc.; Ph. inorganico 13,4 mgrs. em 100 cc.; Calcio 10,3 mgrs em 100 cc.; Potassio 28 mgrs. em 100 cc.; Sodio 328 mgrs. em 100 cc.. O exame hematologico revelou 11% de hemoglobina; 960.000 hematias por mm.³; e 5.200 leucocytos por mm.³. A formula leucocytaria revelou augmento dos neutrophilos, com 74% dos segmentados. A proporção entre sôro o coagulo foi 9 x 3 cc. A reacção de Wassermann no sôro sanguineo foi negativa. A insufficiencia renal se traduziu no caso em estudo, por modificações humoraes, particularmente pela azotemia elevada, pelo augmento da creatinina, do phosphoro inorganico e do indican. Em contraste com a existencia de taes modificações, o doente não apresentou os signaes clinicos observados nos casos emque a azotemia se mantem elevada, reproduzindo tal facto, o quadro clinico descripto para a necrose symmetrica da cortex renal. ABSTRACT In a mortal case of ophidism, in an individual 15 years old, bitten by a snake (Bothrops jararaca) on the external face of his right leg and who died 26 days after the accident, the AA. describe the pathologic-anatomical changes met with and the modifications of the metabolism put into evidence through chemical blood examinations. The main changes there existing are located in the kidneys, which present changes of diffused glomerulonephritis and the typic features of symmetrical cortical necrosis. Among the changes of greater significance there are, moreover, observed vascular injuries of great intensity and essentially constituted by a process of productive endoarteritis. The necrosis of the cortex renis, in view of the intensive vascular changes (productive endoarteritis) conveying the obliteration of the arteries, is considered as a direct consequence of such vascular changes. The renal vessels, which are the seat of the inflammatory process, are the interlobar, arciform and interlobular arteries, but mainly the arteriolary ramifications of the cortical layer. The process of endoarteritis always assumes a progressive character so that the vascular lumen, little by little, is getting obstructed. In opposition to what has been observed in the cases, quoted in the literature, of symmetrical necrosis of the cortex, in which the parenchymatous changes are consecutive to thrombosis of the renal vessels, in the present case this appearance was not verified, there being observed only the existence of obliterating productive endoarteritis. The AA. consider the kidney changes in their case as resulting from the slow and prolongated action of the snake venom on the renal structures, on the strength of the following facts already known and agreed to: elimination of snake venom through the kidneys; capability of the same venom of determining diffused glomerulonephritis, and action of snake venom on vascular endothelium, turned essentially easier by the specific function of the organ. The modifications of metabolism were shown by urine and blood changes. Urine was eliminated in very small quantities (50 cc. in 24 hours); yet, absolute anuria was not observed. Hyaline and granular casts, as well as white blood cells and kidney cells along with albuminuria, were present. Hematologic examination revealed 11% of hemoglobin; 960.000 red blood cells per cmm., and 5.200 leukocytes per cmm.; differential blood count revealed increase of neutrophil leukocytes along with 74% of segmentated ones. The rate between serum and clot was 9 x 3 cc. Wassermann's test in blood serum was negative. The chemical blood examinations revealed: Total proteins 7.61 grs per 100 cc.; Albumin 2.39 grs. per 100 cc.; Globulin 5.22 grs. per 100 cc.; Urca 6.42 grs. per 100 cc.; Fibrinogen 0.324 grs. per 100 cc.; Indican +++; Plasmal cl. 339 mgrs. in 100 cc.; Globular cl. 170 mgrs. in 100 cc.; Cholesterol 163 mgrs. in 100 cc.; Creatinin 260 mgrs. in 100 cc.; Inorganic phosph. 13.4 mgrs. in 100 cc.; Calcium 10.3 mgrs. in 100 cc.; Potassium 28 mgrs. in 100 cc.; Sodium 328 mgrs. in 100 cc.. The renal insufficiency in the case studied was shown by humoral modifications, particularly by increased azotemia, by the increase of creatinin, inorganic phosphorus and indican. In opposition to the existence of such modifications, the patient did not present the clinical evidence observed in cases in which azotemia is at a high degree, a fact which reproduces the clinical aspect as described for the symmetrical necrosis of cortex renis. Texto completo disponível apenas em PDF. Full text available only in PDF format.


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A. Penna de Azevedo, J. de Castro Teixeira. Intoxicação por veneno de cobra: necrose symetrica da cortex renal: uremia, Memórias do Instituto Oswaldo Cruz, 23-37, DOI: 10.1590/S0074-02761938000100002